Medicare Part D – Prescription Drug Program

Medicare Part D – General Coverage Information

Many people rely on prescription drugs to help maintain and improve their health, and Medicare can help cover the costs.  There are two ways of getting prescription drug coverage. If you choose to get your benefits through Original Medicare, you will need to join a stand-alone PDP (Prescription Drug Plan).  (Note: Original Medicare and Medigap plans do not help cover the costs of prescription drugs.) If you choose to get your Medicare Part A and Part B benefits through a Medicare Advantage plan, you may choose one that includes prescription drug coverage, sometimes referred to as a Medicare Advantage Plan with prescription drug coverage, or an “MA-PD.”

Regardless of whether you have stand-alone PDP, or your drug coverage is packaged in an MA-PD, it is crucial that you compare your options, as the coverage can differ greatly. You will want to choose coverage that fits your current needs, preferences, and budget, and will protect your financial security now and in the future. You can review a plan’s formulary (list of covered drugs) before enrolling and make sure that your current medications are covered. You can compare premiums, deductibles, and copayments, and find a plan that will be right for you.


Most Medicare Prescription Drug Plans charge a monthly fee, but this monthly premium can vary between plans. (You pay this in addition to the Medicare Part B premium.) Most people only pay their Part D premium, but .if you don’t sign up for Part D when you’re first eligible, you may have to pay a Part D late enrollment penalty.

It’s important to note that if your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain limit, you may pay a Part D income-related monthly adjustment amount (Part D-IRMAA). This extra amount is in addition to your monthly plan premium, and is paid directly to Medicare, not to your plan.  If you are required to pay this D-IRMAA, you must do so or risk losing your Part D coverage.

Frequently Asked Questions

Q: Is prescription drug coverage included in Original Medicare?

A: Original Medicare helps cover the costs of many medical expenses, but it does not help pay for prescription drugs. In order to have prescription drug coverage with Original Medicare, you will need to enroll in a stand-alone Prescription Drug Plan (PDP).


Q: Can I get drug benefits through a Medigap/Medicare Supplement plan?

A: Even though Medigap policies can help cover the costs that Original Medicare does not, Medicare Supplement plans do not help pay for prescription drugs. If you have Original Medicare and a Medigap policy, you may want to consider enrolling in a stand-alone Prescription Drug Plan (PDP).


Q: Am I required to have prescription drug coverage?

A: You are not required to have prescription drug coverage as a Medicare beneficiary, but the costs of much-needed medications may be overwhelming without any help paying for them. Even if you do not need any medications when you are first eligible for Medicare, you may want to consider enrolling in a PDP to avoid paying a late enrollment penalty later.


Q: I don’t take prescription drugs. Can I just join a plan later if I need them?

A: Once your initial enrollment period has ended, you may join a Prescription Drug Plan, during Open Enrollment/Annual Election Period from October 15 through December 7. For most people, you’ll pay a lower monthly premium if you join when you’re first eligible. You may owe a late enrollment penalty, an amount added to your Part D monthly premium, if you didn’t join a plan when you were first eligible and you didn’t have other creditable prescription drug coverage.


Q: Do all Prescription Drug Plans cost the same?

A: Each Medicare Prescription Drug Plan and Medicare Advantage Plan with prescription drug coverage (MA-PD) must give at least a standard level of coverage set by Medicare, but they can vary on how much they charge. Whether you enroll in a stand-alone Prescription Drug Plan or join a Medicare Advantage Plan with prescription drug coverage, the costs can vary from plan to plan. PDPs may also offer different tiers, or levels, of pricing for the drugs they cover. Compare plans available to you before enrolling to find the plan that best fits your needs.


Q: How do I know if my prescriptions are covered by a PDP?

A: Every Prescription Drug Plan has a formulary, or list of covered drugs. Plans cover both generic and brand name prescription drugs. The formulary must include a range of drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. The formulary might not include your specific drug. However, in most cases, a similar drug should be available.


Q: If I join a PDP, will I have to use specific pharmacies?

A: Medicare drug plans and MA-PDs have contracts with pharmacies that are part of the plan’s “network.” If you go to a pharmacy that is not in your plan’s network, your plan may not cover your drugs. Along with retail pharmacies, your plan’s network may include preferred pharmacies, a mail-order program, and a 60- or 90-day retail pharmacy program.


Q: Can I get my medications through mail order if I join a PDP?

A: Some plans may offer a mail-order program that allows you to get up to a 90-day supply of your covered prescription drugs sent directly to your home. This is usually a cost-effective and convenient way to fill your prescriptions.


Q: I joined a PDP, but it doesn’t cover my new prescriptions. What can I do?

A: If you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes none of the drugs on your plan’s formulary will work for your condition, you can ask for an exception.


Q: What happens if my Prescription Drug Plan stops covering my medication?

A: If your plan removes a drug you are taking from its formulary, in most cases it must notify you at least 60 days in advance. You may have to change to another drug (that’s similar to the one you’re taking) on the plan’s formulary, or pay more to keep taking the drug. You can ask for an exception to continue using the drug that’s being removed from your plan’s drug list if none of the other drugs on the list will work for your condition. In some cases, if you’re actively taking a drug on the formulary during the calendar year, you can continue taking that drug until the end of the year without paying more.


Q: When do I need to enroll in order to avoid late enrollment penalties?

A: If you are new to Medicare, your initial enrollment period for Part D is the 7‐month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you are eligible for Medicare due to a disability, your coverage starts 24 months after you get Social Security or Railroad Retirement Board (RRB) disability benefits. Your chance to sign up lasts through the 27th month after you get Social Security or RRB benefits.